The future CEO may already be in scrubs

Those capabilities are not new. They are embedded in nursing practice, though we rarely name them that way. Yet nurses remain underrepresented in the CEO role.

To understand what executive leadership looks like when shaped by a nursing foundation—and what healthcare risks by overlooking it—we spoke with three leaders who began their careers at the bedside to help inform our recently published study in Nurse Leader:

• Regina Cunningham, PhD, RN, NEA-BC, FAAN—CEO, Hospital of the University of Pennsylvania
• Douglas Hughes, BSN, MBA—President, Grand View Campus, St. Luke’s University Health System and past President and CEO, Grand View Health
• Candice Saunders, BSN, MBA, MHA, FACHE—President and CEO, Wellstar Health System

Their reflections suggest healthcare may be underutilizing one of its strongest leadership pipelines.

None of you set out to become CEOs. What actually propelled you there?

Saunders: I started as an ICU nurse in South Florida. I loved the intensity and the relationships you build with patients and families in critical moments. But I realized I wanted my impact to extend beyond the four walls of one room.

A chief nurse asked me to lead a maternal-child unit. I told her I didn’t know the specialty. She said, “You don’t need to. You know how to lead. Ask the people who do.”

That shifted something for me. So, I walked in and said, “Teach me.” Leadership is not about being the expert person in the room. It is about creating clarity, setting priorities and helping people focus on what matters most.

Later, when I began participating in board meetings, I saw another reality. I could advocate for patients and nurses all day long. But if I could not speak the language of finance, I could not defend the mission. I needed to translate clinical truth into business strategy—and back again.

There were moments I was underestimated. Early on, I had to prove that my clinical background was not a limitation. Over time, I learned that credibility comes from fluency—in operations, finance and strategy—not from abandoning your roots.

Hughes: I didn’t wake up one day and decide I wanted to be a CEO. Early in my career, I had two job offers—one to be a full-time paramedic, which I loved, and one to be a nursing supervisor. I chose the supervisor job because it was intimidating. I have found that usually means there is something to learn.

Second-shift nursing supervisor is one of the toughest jobs in healthcare. You feel alone. If something goes wrong, you figure it out. You are constantly triaging—not just patients, but staffing issues, physician conflicts and throughput problems. That role trains you to think clearly under pressure.

When I later moved into operations, people asked why I left “the nursing side.” I never saw it that way—I saw it as widening the field. I did not want to be limited to solving problems inside one silo. If food service was not working or environmental services needed improvement, I wanted to help fix that too.

I didn’t know I was preparing for a CEO role. I was just taking on bigger problems.

Cunningham: As a young oncology nurse at Memorial Sloan Kettering, I became fascinated by how nursing practice was organized. Advanced practice nurses were influencing patient outcomes in profound ways. It wasn’t just their clinical expertise. It was how the work was structured—how role clarity and systems design amplified impact.

That observation stayed with me.

Becoming a nurse manager was a proving ground. Culture is built or broken at the unit level. If you get that right, everything else flows from it.

The first time someone suggested I apply for a CEO role, I laughed. I said, “I’m not qualified.” I truly believed that. A mentor sat me down and walked through my experiences—running clinics, overseeing research and managing budgets—and said, “You are already doing enterprise leadership.”

Sometimes others see your readiness before you do.

What nursing competencies translated most directly to the CEO role—and where did you have to stretch?

Hughes: Triage. That is the simplest answer. In the emergency department, someone walks in crying, someone else is bleeding and someone else might be having a heart attack. You learn to assess quickly and calmly. As a CEO, it’s no different. There are always 10 issues competing for attention. The skill is knowing which one truly requires escalation. You also learn not to panic. That steadiness matters at the executive level.

The stretch was letting go of fixing everything myself. At scale, your job is not to solve every problem. It is to set direction and build accountability.

Saunders: Nurses are trained problem solvers. At the bedside, you solve the problem in front of you. As a CEO, you decide which problems the organization will focus on. That’s a different muscle.

I often describe the journey as moving from warrior to diplomat. At the bedside, urgency drives everything. In the boardroom, urgency still exists but influence is the lever. You advocate fiercely, but you build coalitions. You work through governance, politics and capital strategy.

That evolution does not mean losing your advocacy. It means expanding it. And it requires comfort with power—not dominance, but influence.

Cunningham: Coordination and boundary spanning are foundational skills that many nurses have. Nurses orchestrate care across disciplines—physicians, therapists and pharmacists—and families, as well as settings of care. This is similar to enterprise leadership. Clinical experience and expertise help to ground judgment and decision making. When operational issues intersect with patient care, I understand the stakes immediately.

Finance was my stretch area. I had a good understanding of managing expenses but less familiarity with the revenue side of the house. When I came into the CEO role, I asked one of our finance leaders to walk through the budgets with me in detail for a full year. Understanding these details truly imposed discipline in revenue allocation decisions. It strengthened my advocacy because I could articulate from both a financial and clinical perspective. Humility is not weakness in leadership. It is acceleration.

For each of you, that preparation came with moments of discomfort. What was the hardest moment in your transition from clinical leader to enterprise executive?

Saunders: The hardest shift was recognizing that not every right answer is immediately actionable. At the bedside, if you know the right thing to do, you do it. In enterprise leadership, you may know the direction you want to go but timing, capital constraints and stakeholder alignment matter.

There were moments early on when I thought, “Why are we still debating this?” Over time, I understood that governance is not obstruction. It’s accountability. You have to bring people with you—board members, physicians and community leaders. That takes patience and influence.

Urgency does not disappear at scale. It becomes disciplined.

Hughes: For me, it was losing the immediacy of feedback. As a frontline leader, you see the impact of your decisions right away. At the enterprise level, decisions play out over months or years. You have to get comfortable making calls without instant validation.

The other shift was realizing that your presence carries weight whether you intend it to or not. When you speak, people act. You learn to be more measured. Sometimes your job is to ask the right question and then let the team work.

Cunningham: The most difficult transition was moving from operational immersion to strategic altitude. In clinical and operational roles, you are close to the work. As a CEO, you must zoom out. You are responsible for resource allocation, long-term positioning and enterprise risk.

I had to resist the impulse to dive into every operational detail and instead ask, “Is this a pattern or an anecdote?” and “What does the data tell us?” That discipline ensures you are leading the system, not reacting to individual events.

The shift is not about stepping away from patient care. It is about stewarding the conditions under which care happens and ensuring that the best possible environment is created.

What experiences most accelerated your readiness for enterprise leadership?

Saunders: Board exposure was pivotal. Sitting in governance meetings changes how you see the organization. You begin to understand fiduciary responsibility and long-term strategy in a different way.

Owning a P&L also changed my perspective. Financial stewardship is not separate from mission. It sustains it.

I also sought roles outside my comfort zone. Lateral moves stretch your range. Each new scope expanded my understanding of how the pieces fit together.

Hughes: Taking responsibility for departments outside nursing accelerated everything. When you oversee facilities or support operations, you start to understand the hospital as a system.

Leading through crisis was another accelerator. Pressure clarifies priorities.

And I asked for feedback. Mentors who were candid with me shortened the learning curve.

Cunningham: Formal responsibility for complex portfolios was critical. Running ambulatory networks and managing large budgets required integrating clinical quality, workforce strategy and financial performance simultaneously.

Intentional financial education accelerated readiness as well. I treated margin management as a discipline to master.

And exposure to governance reframed accountability. Enterprise leadership is not a single promotion. It is the cumulative integration of clinical insight, operational oversight and financial stewardship, and strategic growth over time.

Leadership can be isolating. What keeps you grounded?

Saunders: During the pandemic, I thought about the nurses walking into COVID units every day. I asked myself, “How can I be tired when they are still showing up?”

I also hike. I get outside. If I don’t reset that way, it shows.

Hughes: I sit in the cafeteria—in the middle. I want staff to approach me with what is bothering them. If people have to schedule time to tell you what is broken, you are too far away.

Cunningham: I round on evenings and weekends. My executive team rotates Saturday coverage in the hospital. Leadership presence matters.

Healthcare is a public good. Remembering that and staying anchored in purpose keeps the daily pressures in perspective.

What should nurses understand about executive leadership that is often misunderstood?

Cunningham: Seeking executive leadership is not abandoning clinical identity. It is scaling it. But you must be willing to speak the language of enterprise including governance, risk, financial strategy and strategic growth. Boards are looking for mission-driven stewardship, strong advocacy for the delivery of high-quality care, and executive teams that are focused on performance and can deliver.

Hughes: Titles do not create impact. Scope of influence does. Chase responsibility, not position.

Saunders: Do not rush your timeline. Leadership is cumulative. Lateral moves matter, stretch roles matter. And claim your voice.

What would healthcare look like if more CEOs came from nursing?

Saunders: You would see deeper alignment between strategy and care delivery because the person setting direction has lived the consequences of misalignment.

Hughes: You would see leaders comfortable in complexity, but steady in it.

Cunningham: You would see decisions that instinctively balance patient impact and workforce sustainability. Those priorities are structurally linked.

The bigger question: Why aren’t more organizations recognizing nursing as preparation for enterprise leadership?

What emerges from these conversations is not a collection of individual success stories—it’s a pattern. Cunningham, Hughes and Saunders describe capabilities that mirror the demands of modern chief executive leadership. Healthcare is at a critical juncture.

The capabilities required of today’s CEOs—systems thinking, crisis management, workforce leadership and financial discipline—are the very skills developed in nursing practice. The issue is not whether nurses can lead at the highest level. It is whether organizations are intentionally designing pathways, sponsorship and selection processes that recognize nursing as enterprise preparation.

Healthcare needs leaders who can hold margin and mission in the same frame without treating either as negotiable. Leaders who understand suffering, systems and stewardship can translate between them.

Nursing has been doing that work for generations. The next step is not proving readiness; it’s claiming scale.